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Abstract

Background

Misconceptions about antibiotic use among community members potentially lead to inappropriate
use of antibiotics in the community. This population-based study was aimed at examining
common knowledge and beliefs about antibiotic use of people in an urban area of Indonesia.

Methods

The population of the study was adults (over 18 years old) in Yogyakarta City. A cluster
random sampling technique was applied (N = 640). Data were collected using a pre-tested
questionnaire and analyzed using descriptive statistics and correlation.

Results

A total of 625 respondents was approached and 559 respondents completed the questionnaire
(90% response rate). Out of 559 respondents, 283 (51%) are familiar with antibiotics.
Out of 283 respondents who are familiar with antibiotics, more than half have appropriate
knowledge regarding antibiotic resistance (85%), allergic reactions (70%), and their
effectiveness for bacterial infections (76%). Half these respondents know that antibiotics
ought not to be used immediately for fever (50%). More than half have incorrect knowledge
regarding antibiotics for viral infections (71%). More than half believe that antibiotics
can prevent illnesses from becoming worse (74%). Fewer than half believe that antibiotics
have no side effects (24%), that antibiotics can cure any disease (40%), and that
antibiotic powders poured onto the skin can quickly cure injuries (37%). Those who
are uncertain with these beliefs ranged from 25% to 40%. Generally, these respondents
have moderate knowledge; where the median is 3 with a range of 0 to 5 (out of a potential
maximum of 5). Median of scores of beliefs is 13 (4 to 19; potential range: 4 to 20).
The results of correlation analysis show that those with appropriate knowledge regarding
antibiotics would also quite likely have more appropriate beliefs regarding antibiotics.
The correlation is highest for those who are male, young participants, with higher
education levels, and have a higher income level.

Conclusions

Misconceptions regarding antibiotic use exist among people in this study. Therefore,
improving appropriate knowledge regarding antibiotic use is required.

Keywords:

Knowledge; Beliefs; Antibiotics; Self medication

Background

People’s misconceptions of antibiotics can potentially lead to inappropriate self
medication with either prescribed or non-prescribed antibiotics
[1]. A review about antibiotic use in developing countries by Radyowijati and Haak
[2] reported that people believed antibiotics as “an extraordinary medicine” or “a powerful
medicine” or “a strong medicine” which are able to prevent and cure any diseases or
symptoms. Misconceptions and lack of basic knowledge about antibiotic use have also
been reported by several studies across populations in both developed and developing
countries
[3-12]. Patients’ demand for antibiotic prescription and the practice of using antibiotics
without prescription by community members is influenced by such misconceptions
[6,8,13].

Knowledge and beliefs are social cognitive factors at an individual level that influences
health-related behavior, including the behavior of using antibiotics. Knowledge by
itself is not enough to change behavior, but does play an important role in shaping
beliefs and attitude regarding a particular behavior
[14]. Consequently, in the context of antibiotic use, inappropriate knowledge of using
antibiotics correctly potentially leads to misconceptions regarding such use. Given
that inappropriate use of antibiotics in the community continues to be a significant
problem in both developed and developing countries
[5,15]; reducing misconceptions regarding antibiotic use among the community members is
imperative.

Information on knowledge and beliefs regarding antibiotic use in the developed countries
in particular among general people has been widely presented
[3,6,7,16]. However, similar knowledge relating to developing world settings, including in Indonesia,
is scarce
[15]. Therefore, this present study is aimed at describing knowledge and beliefs about
antibiotic use among people in an urban area of Indonesia.

Methods

This study was part of a study assessing self medication with antibiotics in Yogyakarta
City Indonesia. Some details regarding methods, in particular sample selection, pre-testing
the questionnaire, and data collection, have been presented elsewhere
[17]. The study area was Yogyakarta City, Indonesia with a population density of about
14,000 persons per square kilometres in 2010. Yogyakarta City is known as a multiethnic
city in Indonesia with the Javanese descent predominates
[18]. Ethics approval was provided by the Human Research Ethics Committees at The University
of Adelaide Australia (H-145-2009; RM No: 9508) and research permit was issued by
the Government of Yogyakarta City Indonesia (Pemerintah Kota Yogyakarta Dinas Perizinan:
070/1970/5328/34).

This cross-sectional population-based survey involved respondents over 18 years who
were randomly selected using a cluster random sampling method. The sample size adjusted
for cluster design was 640. The sampling process involved the sub-districts in Yogyakarta
City which were randomly selected. Households were randomly selected from every sub-district
chosen. One family member was randomly selected from every household chosen.

The questionnaire was presented in Bahasa Indonesia, (i.e. the official language of
the Republic of Indonesia). There was one dichotomized question to assess participants’
familiarity regarding antibiotics, i.e. “Are you familiar with antibiotics? (Yes/No)”.
Then, the “Yes” response was verified, i.e. “If yes, please mention the name/s of
the antibiotic/s”. Questions regarding knowledge were assessed using “Yes”, “No”,
and “Don’t know” responses. A five-point Likert Scale, (i.e. strongly disagree – disagree
- neither disagree nor agree – agree – strongly agree) was used for responses to questions
on beliefs. Items in the questionnaire were structured based on published articles
where people’s knowledge and beliefs about antibiotics in various countries were assessed
[19-23]. The validity of the items in the questionnaire was assessed by a group of local
experts. The clarity of language and the user-friendly structures of the questionnaire
were pre-tested with five people who have similar characteristics with the study population.
The tests resulted in some minor revisions. Details of the questions regarding knowledge
(five items) and beliefs (four items) applied in this study are provided in Table
1. There were also questions about demographic and socio-economic characteristics of
respondents.

Table 1.Items of knowledge and beliefs about antibiotic use self administered to respondents
of the survey of self medication with antibiotics in Yogyakarta City Indonesia

The pre-tested questionnaire was self-administered to the respondents who consented
to participate in this study during March to May 2010. The respondents were assured
that their participation was voluntary and anonymous.

The data were digitally stored and analyzed using SPSS (Statistical Package for the
Social Sciences) version 17. Only data of the participants who were able to correctly
mention the name of one or more antibiotics was included in the data analysis (the
inclusion criteria of data). Those who were not familiar with antibiotics were not
required to answer the questions about knowledge and beliefs about antibiotics. These
cases were coded as missing values and were dropped from the analysis. To assess potential
bias due to these missing values, characteristics of respondents of the excluded data
were compared with the included data using Chi-Square test.

The correct responses of the knowledge items were “No” for K1 and K2 and “Yes” for
K3 to K5. A total of the correct responses were calculated to show the scores of overall
knowledge (ranged from 1 to 5). The overall performance of knowledge was stated as
poor (below the median), moderate (at the median), and adequate (above the median)
[24].

Regarding the belief items, scores of 1, 2, 3, 4, and 5 were assigned respectively
to each option - strongly disagree, disagree, neither agree nor disagree, agree, and
strongly agree. Agreeing to the belief items (B1 to B4) was considered as inappropriate
beliefs. The overall grade of the beliefs was approached using the total scores of
those four belief items (ranged from 4 to 20). As per overall knowledge categorizations,
the overall beliefs were stated as appropriate if the scores were below the median
line, as moderate if they were at the line, and as inappropriate if they were above
the line
[24].

Data about demographic and socio-economic characteristics of respondents are reported
as a percentage and median. The characteristics include gender, age, education achievement,
and family income levels. Correlation analysis was conducted to examine the relationships
between knowledge and beliefs. The strength of the correlation coefficients for two
different groups (i.e. by gender - male and female; by age - younger: below the median
line of age and older: above the median line; by education - lower: senior high school
or less and higher: college or university degree; and by income - lower: less than
US $ 150 and higher: US $ 150 or more) were also compared. The strength of the correlations
was stated as weak at rho = 0.10 to 0.29; moderate at rho = 0.30 to 0.49; and strong
at rho = 0.50 to 1.0 using confidence level of 95% (p < 0.05)
[25].

Results

A total of 559 respondents returned the completed questionnaires (90% response rate).
Out of 559 respondents, 283 (51%) are familiar with antibiotics and are able to mention
the name of antibiotics correctly. Those who are not familiar with antibiotics are
276 respondents. Data from these 283 respondents were analysed.

The socio-economic and demographic characteristics of the respondents are presented
in Table
2. Most participants are male (62%). The median of age is 41 years (range: 18 to 88).
The majority had completed the senior high school (41%) and is in the lowest income
level (i.e. less than US $ 150/month) (45%). Across the socio-demographic characteristics
the proportions of those who were excluded (missing data) are not significantly different
from those who were included, i.e. gender, X2 (1, n = 559) =0.24, p = 0.62, phi = 0.02; age, X2 (1, n = 559) = 0.24, p = 0.62, phi = 0.02; and education level, X2 (1, n = 559) =3.1, p = 0.08, phi = 0.09.

Table 2.Demographic and socio-economic characteristics of respondents of self medication with
antibiotics survey in Yogyakarta City Indonesia

As described in Figure
1, most people in this study (85%) are aware that indiscriminate use of antibiotics
leads to antibiotic resistance. Further, most of the participants are able to correctly
answer that bacterial infections can be treated by antibiotics (76%), that people
can be allergic to antibiotics (70%), and that antibiotics must not be used as soon
as they have fever (50%). On the other hand, most of participants (71%) have incorrect
knowledge regarding the use of antibiotics for viral infections. The median of overall
scores of knowledge is 3; ranged from 0 to 5 (a potential maximum of 5). Regarding
level of knowledge, 31% of respondents are at the poor level of overall scores of
knowledge, 35% have moderate level of knowledge, and 34% have adequate knowledge.

Figure 1.Knowledge about antibiotic use among people in Yogyakarta City Indonesia.

As described in Figure
2, most participants (74%) believe that antibiotics can prevent any diseases from becoming
worse. On the other hand, fewer than half believe that antibiotics have no side effects
(24%), that antibiotics can cure any illnesses (40%), and that antibiotics can cure
skin injuries quickly when they are poured onto the wounds (37%). However, those who
neither agree nor disagree with these beliefs ranged from 25% to 40%. Median of the
overall scores of beliefs is 13; ranged from 4 to 19 (a potential range of 4 to 20).
Percentage of participants with appropriate belief is 29%; moderate belief is 46%;
inappropriate belief is 25%.

Figure 2.Beliefs about antibiotic use among people in Yogyakarta City Indonesia.

Association between knowledge and beliefs is moderate and negative, rho = −0.261,
n = 283, p < 0.01; in which high scores of knowledge associated with lower scores
of beliefs; meaning that the more appropriate knowledge they have, the less misconceptions
they have.

As seen in Table
3, the correlations between knowledge and belief for male is higher than female (r = −0.328
and −0.214); for younger is higher than older (r = −0.323 and −0.212); for those with
the higher education achievement is higher than those with the lower education levels
(r = −0.2345 and −0.197); and for those with the higher income levels is higher than
those with the lower income (r = −0.317 and r = −0.145).

Table 3.Comparing the correlation coefficients of knowledge and beliefs about antibiotic use
by gender, age, education achievements, and economic levels among people in Yogyakarta
City Indonesia

Discussion

Overall results of this study show that most participants had moderate to adequate
knowledge regarding antibiotic use. They were aware with the risks of antibiotic use;
for example, regarding antimicrobial resistance, allergic and possible side effects.
Most of them knew that antibiotics are effective for bacterial infections, but had
inappropriate knowledge regarding antibiotics’ effectiveness for viral infections.
In terms of beliefs about antibiotic use, overall they expressed beliefs that antibiotics
can prevent any symptoms/diseases from becoming worse. Only a few believed that antibiotics
have no side effects; that antibiotics can cure any diseases; and that antibiotics
can be used effectively to cure skin injuries by pouring the powders onto the wounds.
Furthermore, the relationships between knowledge and beliefs suggest that the more
appropriate their knowledge about the use of antibiotics; the fewer misconceptions
they will have regarding the effectiveness of antibiotics.

There are some limitations in this study, in particular regarding the methods used.
Firstly, given that the study involved the population of an urban area of Indonesia,
results of this study would apply more to urban people who are mostly literate, are
able to easily get access to the mass media, and possibly have received more information
about antibiotics than those in rural areas. Secondly, a recognized source of error
in studies of antibiotic use involving lay people is whether the participants are
able to differentiate antibiotics from other types of medicines
[2]. However, participants who were not familiar with antibiotics were excluded from
this study, to minimize bias. Given that nearly half of the cases were excluded, checking
was done to assess bias due to these missing values. As mentioned earlier there are
no significant differences in any of the socio-demographic characteristics between
those who were included and those who were excluded.

Generally, lay people in both developed and developing countries are aware that antibiotics
are effective for bacterial infections
[6,11,26]. Interestingly, there is inconsistency in the literature regarding the appropriate
knowledge among the community members about the effectiveness of antibiotics in treating
viral infections
[3,6,26,27]. Furthermore, inconsistent information also exists in terms of people’s knowledge
about other therapeutic effects of antibiotics; for example the immediate use of antibiotics
for treating a fever or treating skin injuries by pouring antibiotics powders onto
them
[6,11,28]. Evidence mentioned earlier demonstrates that such misconceptions regarding therapeutic
effects of antibiotics do exist among the general public. These facts give evidence
to confirm that people are not able to differentiate the types of causal agents of
infectious disease, (e.g.: bacteria, viruses, fungal) and they have very limited knowledge
regarding the basic mechanism of how the antibiotics work.

In contrast to those misconceptions, people in this study had a sufficient knowledge
regarding the risks of using antibiotics, such as antibiotic resistance and allergies.
These findings are in line with most other studies from elsewhere
[6,11,27-31], but in contrast to what was reported by the European study
[5]. People in this study were familiar with the term “resistance” although information
on resistance is not usually provided when purchasing antibiotics
[32]. However, it should be noted that when lay people talk about “resistance”, this term
could mean human resists to antibiotics rather than microorganisms to antibiotics.
Another possibility is that they might perceive the term of resistance as “something
dangerous”. Although people may have inappropriate understanding regarding the meaning
of resistance, these findings, somehow, indicate their awareness regarding the risks
of antibiotic use.

In this present study, association between beliefs and knowledge is negative and moderate.
This means that the more appropriate knowledge people have, the less misconceptions
they have. This correlation is likely to be held by the population and is higher for
male, for younger, for those with higher education, and for those with higher income
level. This finding suggests that women, older people, and those with lower formal
education and income levels could be prioritized in any efforts for reducing misconceptions
about antibiotic use.

Inappropriate use of antibiotics exists among Indonesians, as is indicated by the
previous studies
[17,23]. Appropriate beliefs regarding antibiotic use may lead people becoming more aware
of the disadvantages of using antibiotics inappropriately. Based on the findings of
this present study, further studies are suggested. Firstly, a similar study needs
to be conducted in rural areas of Indonesia, as this present study represents the
urban people. Secondly, a better understanding is needed on the extent to which beliefs
can influence people using antibiotics in inappropriate ways; for example using antibiotics
without medical consultation. Thirdly, it is imperative to develop a sustainable intervention
program to reduce misconceptions of antibiotic use and to increase public’s awareness
about the risks of inappropriate use of antibiotics.

Conclusions

We believe that this study is useful in describing people’s knowledge and beliefs
regarding antibiotic use among Indonesians in urban areas. The findings may be useful
to help develop intervention to decrease misconceptions regarding antibiotic use and
to increase people’s awareness regarding the risks of inappropriate use of antibiotics
in the community.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

All authors contributed to conception and design of the study. AW carried out data
collection, data analysis, data interpretation and drafted the manuscript. JEH, CdeC,
and SS checked and clarified data analysis and data interpretation; and revised draft
of the manuscript critically. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank Prof. dr. P.J. van den Broek, LUMC Netherlands (feedbacks
on the research proposal and the draft of the questionnaire); colleagues at the Centre
of Clinical Pharmacology and Drug Policy Study Yogyakarta Indonesia; the field work
team (Anna S. Yuliasari, Andrian Liem, Wahyu Satyawan, Anna Maria Lisa Angela, Hiasinta
Primastuti, and Yohanes Dedy Setiawan); Martin Schumacher (English); the University
of Adelaide and Sanata Dharma Foundation (general support).This work was funded by
the Ministry of Education, Indonesia.

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